2009年NCCN肺癌指南指出：3维适形治疗可用于各型非小细胞肺癌患者
2009年NCCN肺癌指南关于放疗的部分原文如下：Modern 3-dimensional conformal RT techniques with CT or CT/positronemission tomography (PET)--based treatment planning should be used on all patients.The dose volume histogram (DVH) for the lungs,esophagus, heart, liver, kidney, and spinal cord should be used to minimize normal tissue toxicity (see NSCL-C ). Whenever feasible,respiratory management techniques (such as 4-dimensional CT and respiratory gating) should be incorporated in the radiation set up and delivery. Treatment planning should be on CT scans obtained in the treatment position. IV contrast for diagnostic or simulation CT should be used for better target and normal tissue delineation whenever possible. PET/CT is preferable for treatment plans rather than CT alone for the gross tumor volume (GTV) delineation in cases with substantial atelectasis.
In general, photon beam energy between 4-10 MV is recommended formost patients. If a large tumor is involving the mediastinum or the primary tumor is a large and proximal lesion with patient’s separation more than 20 cm, 15 MV or 18 MV photon energy can also be used. If the tumor is fixed to the vertebral body, located at the superior sulcus,or involves the bilateral mediastinum, intensity-modulated radiotherapy (IMRT) should be considered to avoid overdose to normal tissues. Involved field radiation to high dose without elective nodal treatment has been shown to have less toxicity, superior survival, and low risk of isolated nodal relapse.In patients receiving radiation therapy orchemoradiation with curative intent, treatment interruptions or dosereductions for manageable acute toxicities (that is, grade 3 esophagitis, pneumonitis, hematologic toxicities) should be avoided by following the recommended dose-volume constraints (see NSCL-C ). 98-100 In the preoperative chemoradiation setting, a total dose of 45-50 Gy in 1.8-2 Gy fractions should be used to treat all volumes of gross disease (see NSCL-5and NSCL-C ).101 Doses greater than 50 Gy in the preoperative setting have been reported to be safe at select institutions; however, this is still considered experimental.To avoid postoperative pulmonary toxicity, preoperative chemoradiotherapy should be avoided if pneumonectomy is required.Surgery in a field that has had 60 Gy is difficult, because the landmarks disappear with high doses of radiation. Thus, surgeons are often wary of resection in areas that have previously received RT doses of more than 45 Gy, especially patients who have received RT doses of more than 60 Gy (ie, patients who have received definitive concurrent chemoradiation). Therefore, the radiation dose should be carefully considered if patients might be eligible for surgery. Radiation therapy should continue to definitive dose without interruption if the patient is not a surgical candidate. Postoperative radiation should include the bronchial stump and mediastinum. A total dose of 50 Gy should be delivered in 1.8 to 2 Gy fractions for negative margins. For extranodal extension or microscopic positive margins, a total dose of 54-60 Gy (in 1.8 to 2 Gy fractions) should be used (see NSCL-C ). For gross residual tumor, a total dose up to 70 Gy should be used. Because of the higher risk of local failure, concurrent adjuvant chemoradiation can be used if recommended in the guidelines and if the patient can tolerate it.
In the definitive concurrent chemoradiation setting, a total radiation dose up to 74 Gy in 2 Gy fractions should be used to treat all volumes of gross disease.Three-dimensional treatment planning is imperative with dose volume histogram assessments of lung function to estimate the risk of pneumonitis (see NSCL-C ). 110,111 Elective nodal radiation is not mandated.Studies suggest that stereotactic body radiotherapy (SBRT) andradiofrequency ablation (RFA) may be options for node-negativepatients who either refuse surgery or cannot tolerate surgery because of poor PS, significant cardiovascular risk, poor pulmonary function, and/or comorbidities. When stereotactic radiosurgery was used in 245 patients (T1-2), local control was 85% at 2 years and 5 years.Radiation Therapy Oncology Group (RTOG) 0236 trial is currently assessing SBRT. Optimal candidates for SBRT include patientswith node negative peripheral tumors less than 5 cm.Optimal candidates for RFA include patients with an isolated peripheral lesion less than 3 cm; RFA can be used for previously irradiated tissue and for palliation.119 A recent study with RFA in 33 patients with NSCLC yielded overall survival of 70% (95% CI, 51%–83%) at 1 year and 48% (30%-65%) at 2 years. Patients with stage I NSCLC (n=13) had a2-year overall survival of 75% (45–92%). RT with (or without)chemotherapy should be offered as potentially curative treatment to patients with stage I and II NSCLC who are medically inoperable but ofreasonable PS and life expectancy (seeNSCL-Band NSCL-C ).However, a study in 4,357 patients with stage I or II NSCLC who did not have surgical resection found that median survival was improved (by 5-7 months) in patients treated with RT, although 5-year survival was not significantly different when compared with patients not receiving RT.
[ 本帖最后由 围棋 于 2009-5-13 17:12 编辑 ] 不知我的理解是否正确，请高手指点。 3维适形治疗 早就用于各型非小细胞肺癌患者 若水说得对，我看到2008年nccn指南中已经提到3维适形治疗可用于各型非小细胞肺癌。可遗憾的是，去年我父亲在南京八一医院化疗科治疗时，因父亲担心化疗的副作用，因此询问医生是否可做适形治疗时，医生却建议不做，认为应该做全身治疗，即化疗。不知道这种回答是否有利益成分在里面。我现在回想起来，觉得如果去年就做了适形治疗，也许今年父亲的病情会不一样。
其中，我自己也有责任。去年我就应该认真研究NCCN指南，而不应该盲目信任医生。唉----- 医生要你们化疗没错 化疗可能没有错。因为对于晚期病人来说，化疗是一定要实施的。但是，医生不应该轻易放弃其他疗法或不介绍其他疗法，使病人减少了使用其他疗法的可能性，正确的做法是医生应请放射科、外科医生一起会诊，确定哪种疗法或联合疗法是最好的方法，从而给病人更好更专业的选择。我感到遗憾的主要是医生并未请其他科的专家会诊，进入病区后首先强调的是挂水化疗，我父亲因此失去了一次经讨论确定方案的好机会，这对我父亲而言是不合理的。若水，你说呢？
[ 本帖最后由 围棋 于 2009-5-18 15:54 编辑 ] 我今天到放射科请医生看看我父亲是否可以用3维定向治疗，放射科医生的答复是肯定的。现在我的难题是，是放射科的医生对，还是化疗科的医生对呢？哪位医生能给我权威的解答呢？若水，你能吗？ 原帖由 围棋 于 2009-5-18 16:03 发表 http://www.51qiji.com/images/common/back.gif
我今天到放射科请医生看看我父亲是否可以用3维定向治疗，放射科医生的答复是肯定的。现在我的难题是，是放射科的医生对，还是化疗科的医生对呢？哪位医生能给我权威的解答呢？若水，你能吗？
身体好的话,放化疗结合综合治疗是比较好的
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